prior authorization bypass pepcid® oral susp …idoctorus.com/pdf/pepcid oral susp.pdf · please...
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Please Note: Medical Necessity Prior Authorization may be overrided for both formulary coverage and benefit design restrictions. They are issued at the full discretion of the benefit manager.
MEMBER INFORMATION
Last Name
Member ID Date of Birth
DRUG INFORMATION
Drug Name
Quantity ICD-9
Directions
Diagnosis
Medication/ailure Reason:
IgE:______________
ESR:_______________ CRP:_______________ # Joints:_______________ %BSA:______________
Height:_______________ Weight:______________ BMI:_______________
HA1C:_______________ Hemoglobin:_______________ Hematocrit:_______________ T-Score:_____________
Dialysis:_____________ Long Term Care Facility:_____________ Self Injecting:_____________timulation
test:__________/__________ Growth velocity:___________ #Chemotherapy cycles/month:__________ Mini-
Mental Status Test:____________ Baseline Free testosterone/Total testosterone:________RNA viral
load:______________ Viral Genotype:_______________ ALT:_______________
NPI #
PRIOR AUTHORIZATION BYPASSPepcid® Oral Susp famotidine oral susp)
Bypass the Prior Authorization by Modifying the following Prescription Forms to the Patient's Needs
SAMPLE
compounded famotidine 40mg/5ml ; quantity #
sig:1 teaspoon orally at bedtime as dir ected by physician Dx: REFLUX ESOPHAGITISID 10: K 21.9
Page 1 of 2
Prescriber Information Last Name:
DEA/NPI:
Phone
- -
First Name
Specialty:
Fax
- -
Member Information Last Name:
Member ID Number
First Name
DOB:
- -
Medication Information:
Drug Name and Strength:
__________________________________________________
Diagnosis:
__________________________________________________
Quantity and Dosing:
_______________________________________________
Duration:
_______________________________________________
When advised below, please include all requested fax documentation (lab results, etc.) when submitting this PriorAuthorization fax form; not submitting requested documentation could delay the clinical review process.
Zantac (ranitidine) syrup, Tagamet (cimetidine) solution, Axid (nizatidine) solution, Pepcid (famotidine) suspension Prior Authorization Form
You must answer ALL of the following questions
1. Is the patient 18 years of age or older? Y NPatients Greater than 18 Years of Age
2. Has the patient received the liquid H2-blocker product before? Use must be confirmed in past claimshistory or submitted chart notes.
Y N
3. Does the patient have an enteral feeding tube? Y N4. Does the patient have difficulty swallowing tablets and capsules? Please submit documentation. Y N5. Is the patient using other oral tablets or capsules, as confirmed by their previous 4 month claims profileor submitted chart notes?
Y N
6. Has the patient tried a generic H2 blocker liquid product (e.g., generic ranitidine)?Please submit documentation.
Y N
Patients Less than 18 Years of Age
2. Is this request for initial or renewal of therapy? (Please circle)
Initial Renewal
Initial Therapy You must answer ALL of the following questions
3. Does the patient have an enteral feeding tube? Y N4. Does the patient have difficulty swallowing tablets and capsules? Please submit documentation. Y N
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5. Is the patient using other oral tablets or capsules, as confirmed by their previous 4 month claims profileor submitted chart notes?
Y N
6. Has the patient tried a generic H2 blocker liquid product (i.e. generic ranitidine)?Please submit documentation.
Y N
Renewal Therapy You must answer ALL of the following questions
1. Is the patient using other oral tablets or capsules, as confirmed by their previous 4 month claims profileor submitted chart notes?
Y N
Please note, not all drugs/diagnoses are covered on all plans.
Comments: ________________________________________________________________________________________ Information given on this form is accurate as of this date.
Prior Authorization forms are located on the Cover Page. Print a new form for each request as forms are updated periodically.
__________________________________________________________ _________________________ Prescriber or Authorized Signature Date
__________________________________________________________ Authorized Medical Staff – Name/Title
Attention Healthcare Provider: If you would like to discuss this request with a medical professional, please contact the Prior Authorization Departmentwhose numbers appear on the Cover Page.
I understand that USDoctor's use or disclosure of individually identifiable health information, whether furnished by me or obtained by another source such as medical providers, shall be in accordance with federal privacy regulations under HIPAA (Health Insurance Portability and Accountability Act of 1996).
Please Note: Medical Necessity Prior Authorization may be utilized to override both formulary coverage and benefit design restrictions. They are issued at the full discretion of the benefit manager.
PRIOR AUTHORIZATION FORM: COVER PAGE
MEMBER INFORMATION
First Name Last Name
Plan
Member ID Date of Birth
DRUG INFORMATION
Drug Name
Quantity ICD-10
Directions Duration of Therapy
Diagnosis PLEASE LIST ALTERNATIVE THERAPIES THAT HAVE BEEN ATTEMPTED AND ANY OTHER PERTINENT INFORMATION RELATED TO DRUG AND/OR DISEASE STATE. IF NOT PRESENT, WITHIN NORMAL LIMITS WILL BE USED FOR THE REVIEW.
Medication/Failure Reason:
IgE:______________
ESR:_______________ CRP:_______________ # Joints:_______________ %BSA:______________
Height:_______________ Weight:_______________ BMI:_______________
HA1C:_______________ Hemoglobin:_______________ Hematocrit:_______________ T-Score:_____________
Dialysis:_____________ Long Term Care Facility:_____________ Self Injecting:_____________
Stimulation test:__________/__________ Growth velocity:___________ #Chemotherapy cycles/month:__________
Mini-Mental Status Test:____________ Baseline Free testosterone/Total testosterone:__________/_________
HCV RNA viral load:______________ Viral Genotype:_______________ ALT:_______________
PHYSICIAN INFORMATION
Physician Signature Date
Physician Name NPI #
Phone Number Fax Number
Action Needed
Only mark Urgent when standard review time would seriously harm the member’s life or health or ability to regain maximum function
Urgent For Review
Pharmacy Fax
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Contact Information:
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